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1、危重病患者的血流动力学监测focus on PiCCO,北京协和医院杜斌,血流动力学监测增加患者病死率,Connors AF Jr,Speroff T,Dawson NV,Thomas C,Harrel FE Jr,Wagner D,Desbjens N,Goldman L,Wu AW,Califf RM,Fulkerson WJ Jr,Vidaillet H,Broste S,Bellamy P,Lynn J,Knaus WA.The effectiveness of right heart catheterization in the initial care of critically
2、ill patients.SUPPORT Investigators.JAMA 1996;276(11):889-897,血流动力学监测为何不能改善预后,不恰当的适应症PAC的副作用或并发症获得数据的方法不正确仪器定标错误,或传感器位置错误获得的数据不能反映血流动力学状态错误使用数据(对数据的解读错误)作出治疗决定前未考虑其他相关因素CXR,尿量,血清白蛋白采用的治疗措施无效或有害无需血流动力学监测时未及时拔除PAC,PAC的使用减少:Illinois,USA,Appavu S,Cowen J,Bunyer M.The use of pulmonary artery catheterizati
3、on has declined.Critical Care 2005;9(Suppl 1):P69(DOI 10.1186/cc3132),PAC的使用减少:Illinois,USA,Appavu S,Cowen J,Bunyer M.The use of pulmonary artery catheterization has declined.Critical Care 2005;9(Suppl 1):P69(DOI 10.1186/cc3132),临床评价 vs.血流动力学,目的:评价肺动脉导管(PAC)得到的血流动力学指标是否能够改变患者的治疗设计:前瞻性观察患者:103例留置PAC的
4、患者方法:插管前,请医生对一些血流动力学指标的范围,诊断及治疗方案进行预测插管后,复习患者病例,记录插管时及置管8小时内的血流动力学,Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,临床评价 vs.血流动力学,Eisenberg PR,Jaffe AS,Schuster
5、 DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,临床评价 vs.血流动力学,结果留置PAC后计划治疗方案需要改变58%应用未预计到的治疗方案30%,Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheter
6、ization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,临床评价 vs.血流动力学,结论单纯根据临床表现难以准确预测血流动力学指标PAC监测数据通常能够改变治疗方案,Eisenberg PR,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill
7、patients.Crit Care Med 1984;12(7):549-553,血流动力学数据的解释,临床场景(n=44)心脏外科术后16ARDS 9全身性感染 9心源性休克 5其他情况 5,Squara P,Fourquet E,Jacquet L,Broccard A,Uhlig T,Rhodes A,Bakker J,Perret C.A computer program for interpreting pulmonary artery catheterization data:results of the European HEMODYN resident study.Inten
8、sive Care Med 2003;29:735-741,血流动力学数据的解释,Squara P,Fourquet E,Jacquet L,Broccard A,Uhlig T,Rhodes A,Bakker J,Perret C.A computer program for interpreting pulmonary artery catheterization data:results of the European HEMODYN resident study.Intensive Care Med 2003;29:735-741,血流动力学数据的解释,Squara P,Fourque
9、t E,Jacquet L,Broccard A,Uhlig T,Rhodes A,Bakker J,Perret C.A computer program for interpreting pulmonary artery catheterization data:results of the European HEMODYN resident study.Intensive Care Med 2003;29:735-741,血流动力学参数改变治疗决定,Squara P,Bennett D,Perret C.Pulmonary artery catheter:does the problem
10、 lie in the users?Chest 2002;121:2009-2015,ICU患者的输液治疗,输液治疗的决定因素临床经验中心静脉压或肺动脉楔压,Boldt J,Lenz M,Kumle B,Papsdorf M.Volume replacement strategies on intensive care units:results from a postal survey.Intensive Care Med 1998;24:147-151,临床判断缺乏准确性:PAWP,0,10,15,19,19,15,10,0,预计PAWP(mmHg),测定PAWP(mmHg),Eisenb
11、erg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,No change in planned therapy after catheterization,Change in planned therapy after catheterization,0,临床判断缺乏准确性:CO,0,4
12、.5,7.0,预计CO(L/min),测定CO(L/min),Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,4.5,7.0,临床判断缺乏准确性,Eisenberg PL,Jaffe AS,Schuster DP.Clinical evaluation compared
13、 to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.Crit Care Med 1984;12(7):549-553,How good are our clinical skills?,Cardiac outputWedge pressure,Bayliss(BMJ 83)CCU pts71%62%,临床判断缺乏准确性,Clinical evaluation compared to pulmonary artery catheterization in the
14、 hemodynamic assessment of critically ill patientsEisenberg PR,et al.Crit Care Med 1984;12:349Assessing hemodynamic status in critically ill patients:Do physicians use clinical information optimally?Connors AF,et al.J Crit Care 1987;2:174Therapeutic impact of PAC in the ICUSteingrub,et al.Chest 1991
15、;99:1451PAC in critically ill patients:A prospective analysis of outcome changes associated with catheter-prompted changes in therapyMimoz O et al.Crit Care Med 1994;22:573Hemodynamic and pulmonary fluid status in the trauma patient:are we slipping?Veale WN Jr,et al.Am Surg.2005;71:621,临床判断缺乏准确性,医生常
16、常相信自己的判断,但自信与准确性之间并无相关性与经验较少的医生相比,尽管有经验的医生更为自信,但他们的判断并不准确医生不应盲目根据自己对心脏功能的判断,作为治疗决策的依据,Dawson NV et al.Hemodynamic assessment in managing the critically ill:is physician confidence warranted?Med Decis Making 1993;13:258-266,临床判断血流动力学的准确性,临床重要的血流动力学参数,Squara P,Bennett D,Perret C.Pulmonary artery cathe
17、ter:does the problem lie in the users?Chest 2002;121:2009-2015,心脏手术后患者的血流动力学监测,问卷调查(39个问题)血流动力学监测容量替代正性肌力药物/升压药物输血德国的80个ICU主任问卷回收率69%,Kastrup M,Markewitz A,Spies C,Carl M,Erb J,Groe J,Schirmer U.Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardia
18、c surgery patients in Germany:results from a postal survey.Acta Anaesthesiologica Scandinavica 2007;51(3):347-358.,心脏手术后患者的血流动力学监测,Kastrup M,Markewitz A,Spies C,Carl M,Erb J,Groe J,Schirmer U.Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac s
19、urgery patients in Germany:results from a postal survey.Acta Anaesthesiologica Scandinavica 2007;51(3):347-358.,英格兰与威尔士ICU的CO监测技术,Esdaile B,Raobaikady R.Survey of cardiac output monitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131),英格兰与威尔士ICU的C
20、O监测技术,CO监测技术 2种69%首选经食道多普勒监测CO41%常规监测ScvO220%,Esdaile B,Raobaikady R.Survey of cardiac output monitoring in intensive care units in England and Wales.Critical Care 2005;9(Suppl 1):P68(DOI 10.1186/cc3131),Are We Using PAC Correctly?,PAWP测定中的技术问题,Morris AH,Chapman RH,Gardner RM.Frequency of technical
21、problems encountered in the measurement of pulmonary artery wedge pressure.Crit Care Med 1984;12(3):164-170,PAWP测定中的技术问题,Morris AH,Chapman RH,Gardner RM.Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure.Crit Care Med 1984;12(3):164-170,WP initial WP co
22、nfirmed=11 6 mmHgRange(-13,+22),PAWP测定中的技术问题,Morris AH,Chapman RH,Gardner RM.Frequency of wedge pressure errors in the ICU.Crit Care Med 1985;13(9):705-708,PAWP测定中的技术问题,Morris AH,Chapman RH,Gardner RM.Frequency of wedge pressure errors in the ICU.Crit Care Med 1985;13(9):705-708,ICU医生缺乏PAC的相关知识,目的:评
23、价欧洲国家ICU医生对PAC相关知识的了解程度设计:调查问卷背景:86个欧洲大学及非大学医院ICU对象:从两个欧洲危重病医学会目录中选取134个ICU.其中86个ICU的535名医生参加问卷调查干预:在每个ICU中,所有医生均被要求同时完成一项调查问卷,包括31个多选题,涉及床旁留置PAC的所有方面,Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 19
24、97;25:213-220,ICU医生缺乏PAC的相关知识,Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220,ICU医生缺乏PAC的相关知识,Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart c
25、atheterization at the bedside:time to act?Crit Care Med 1997;25:213-220,ICU医生缺乏PAC的相关知识,Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220,ICU医生缺乏PAC的相关知识,Gnaegi A,Feihl F,Perret C.Intensi
26、ve care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25:213-220,ICU医生缺乏PAC的相关知识,Gnaegi A,Feihl F,Perret C.Intensive care physicians insufficient knowledge of right-heart catheterization at the bedside:time to act?Crit Care Med 1997;25
27、:213-220,Is There an Easy Alternative to This Dilemma?,Central venous catheter,Injectate temperature sensor housing PV4046,Arterial thermodilution catheter,Injectate temperature sensor cablePC80109,PULSION disposable pressure transducer PV8115,PCCI,AP,13.03 16.28 TB37.0,AP 140117 92(CVP)5SVRI 2762PC
28、CI 3.24HR 78SVI 42SVV 5%dPmx 1140(GEDI)625,DPT Monitor cablePMK-206,Interface cablePC80150,Connection cableto bedside monitorPMK-XXX,AUX adaptercable PC81200,PiCCO的技术原理,PiCCO技术由下列两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管:,心输出量的测定:经肺热稀释技术,中心静脉内注射指示剂后,动脉导管尖端的热敏电阻测量温度下降的变化曲线通过分析热稀释曲线,使用Stewart-Hamilton公
29、式计算得出心输出量(CO),心输出量的测定:经肺热稀释技术,经肺热稀释测量只需要在中心静脉内注射冷(8C)或室温(24C)生理盐水,中心静脉注射,右心,左心,肺,PiCCO导管如插在股动脉内,热稀释法测定CO:PiCCO vs.PAC,动脉脉搏轮廓分析,动脉脉搏轮廓分析通过动脉压力波型的形状获得连续的每搏参数通过经肺热稀释法的初始校正后,该公式可以在每次心脏搏动时计算出每搏量(SV),SV,连续心输出量测定:PiCCO,压力曲线下面积,压力曲线型状,动脉顺应性参数,心率,与病人有关的校正因子,t s,P mm Hg,PCCO is displayed as last 12s mean,心输出量
30、的测定:PiCCO vs.热稀释,PiCCO的技术原理,PiCCO技术由下列两种技术组成,用于更有效地进行血流动力和容量治疗,使大多数病人不必使用肺动脉导管:,PiCCO容量参数,全心舒张末期容积GEDV胸腔内血容积ITBV血管外肺水EVLW通过对热稀释曲线的分析,可以得到这些容量参数,全心舒张末期容积(GEDV),全心舒张末期容积(GEDV)是心脏4个腔室内的血容量,胸腔内血容积(ITBV),胸腔内血容积(ITBV)是心脏4个腔室的容积+肺血管内的血液容量,血管外肺水(EVLW),血管外肺水(EVLW)是肺内含有的水量,可以在床旁定量判断肺水肿的程度,容量的测量原理,ln c(I),注射,A
31、t,再循环的影响,MTt,t,e,-1,DSt,c(I),MTt:Mean transit time平均传输时间 half of the indicator passed the point of detection,DSt:Downslope time下降时间 exponential downslope time of TD curve,容量的测量原理,Vall=V1+V2+V3+V4=MTt x FlowMeier et al.J Appl Physiol.1954,V3=最大腔的容积=DSt x FlowNewman et al.Circulation.1951,指示剂由注射点到检测点的
32、平均传输时间MTt由两点间的总容积决定,下降时间DSt由其中最大的腔室决定(比其它腔至少大 20%成立!),flow,V3,V4,V2,V1,注射,检测,胸腔内的容积组成,GEDV,PTV,RAEDV,PBV,LAEDV,LVEDV,RVEDV,EVLW,EVLW,ITTV,PTV=肺内热容积,在一系列混合腔室中具有最大的热容积(DSt 容积)ITTV=胸腔内总热容积,从注射点到测量的热容积之和(MTt 容积)GEDV=全心舒张末期容积=ITTV PTV,容量的测量原理,RAEDV,PTV,LAEDV,LVEDV,RVEDV,胸腔总热容积(ITTV)ITTV=CO x MTtTDa,肺内总热容
33、积(PTV)PTV=CO x DStTDa,全心舒张末期容积GEDV=ITTV PTV,ITBV的测量原理,Sakka et al,Intensive Care Med 2000;26:180-187,ITBV=1.25*GEDV 28.4 ml,r=0.96,ITBVTD(ml),GEDVST(ml),GEDV vs.ITBV in 57 intensive care patients,ITBV准确性的临床验证,Sakka et al,Intensive Care Med 26:180-187,2000,n=209r=0.97,Bias=-7.6 ml/m2SD=57.4 ml/m2,ITB
34、VIST vs.ITBVITD in 209 intensive care patients,容量测量小结,ITTV=CO x MTtTDa,PTV=CO x DStTDa,ITBV=1.25 x GEDV,GEDV=ITTV PTV,PiCCO前负荷指标,在反映心脏前负荷的敏感性和特异性方面,已经证实ITBV和GEDV不但优于CVP及PAWP,也优于RVEDVITBV和GEDV最主要的优点是不受机械通气的影响而产生错误,因此能够在任何情况下提供前负荷情况的正确信息经由GEDV和SV计算得到的全心射血分数(GEF),在一定程度上反映了心肌收缩功能GEF=4 x SV/GEDV,容量负荷反应组与
35、无反应组的CVP,扩容治疗前的肺动脉楔压,p 0.05,扩容治疗前的右室舒张末容积指数,扩容治疗前的右室舒张末面积,p 0.05,CVP/PAWP不能预测扩容反应,Lichtwarck-Aschoff et al,Intensive Care Med 1992;18:142-147,ITBV能够更好地反映前负荷,Lichtwarck-Aschoff et al,Intensive Care Med 1992;18:142-147,预测扩容反应:PAWP/CVP vs.ITBV,1.Michard F,Boussat S,Chemla D,Anguel N,Mercat A,Lecarpenti
36、er Y,Richard C,Pinsky MR,Teboul JL.Relation between Respiratory Changes in Arterial Pulse Pressure and Fluid Responsiveness in Septic Patients with Acute Circulatory Failure.Am J Respir Crit Care Med 2000;162:134-138.2.Rex S,Brose S,Metzelder S,Huneke R,Schalte G,Autschbach R,Rossaint R,Buhre W.Pred
37、iction of fluid responsiveness in patients during cardiac surgery.Br J Anaesth 2004;93:782-788,前负荷指标与SV/CI的相关性,Goedje et al,Eur J Cardiothorac Surg 1998;13(5):533-539;discussion 539-540,心输出量和全身循环阻力,由于脉搏轮廓分析连续测量每搏量和动脉压,可以如下计算得到心输出量(CO)和全身循环阻力(SVR):CO=每搏量 x 心率SVR=(平均动脉压 中心静脉压)/CO,每搏量变异(SVV),对于没有心律失常的机
38、械通气患者SVV反映了心脏对因机械通气导致的心脏前负荷周期性变化的敏感性SVV可以用于预测扩容治疗是否会使每搏量增加,SVmax,SVmin,SVmean,SVmax SVmin,SVV(30秒)=,SVmean,对扩容反应的预测性:CVP vs.SVV,Sensitivity,1 Specificity,Berkenstadt et al,Anesth Analg 2001;92:984-989,-CVP_ SVV,血管外肺水的测定:EVLW,放射影像学(radiology)指示剂稀释技术(indicator dilution technique)显像技术(imaging technique
39、)重力测定技术(gravimetric technique),氧合与肺水肿,静水压升高引起肺水肿CMVFiO2 0.4,Scillia P,Delcroix M,Lejeune P,Melot C,Struyven J,Naeije R,Gevenois PA.Hydrostatic pulmonary edema:evaluation with thin-section CT in dogs.Radiology 1999;211:161-168,血管外肺水与氧合,Martin GS,Eaton S,Mealer M,Moss M.Extravascular lung water in pat
40、ients with severe sepsis:a prospective cohort study.Crit Care 2005;9:R74-R82(DOI 10.1186/cc3025),血管外肺水与病死率,Sturm,In:Practical Applications of Fiberoptics in Critical Care Monitoring,Springer Verlag Berlin-Heidelberg-NewYork 1990,pp 129-139,血管外肺水的测定,当EVLW增加 100%时,胸片才会发生改变Bongard FS,Surgery 1984胸片对EVL
41、W的改变并不敏感Helperin BD,Chest 1984确定患者是否符合ARDS影像学表现时,医生之间存在非常明显的差异Rubenfeldet al,Chest 1999,容量测量小结,ITTV=CO x MTtTDa,PTV=CO x DStTDa,ITBV=1.25 x GEDV,EVLW=ITTV ITBV,GEDV=ITTV PTV,EVLW:PiCCO vs.重力法测定,Sturm,In:Practical Applications of Fiberoptics in Critical Care Monitoring,Springer Verlag Berlin-Heidelbe
42、rg-NewYork 1990,pp 129-139,血管外肺水的临床验证,Sakka et al,Intensive Care Med 26:180-187,2000,Bias=-0.2 ml/kgSD=1.4 ml/kg,n=209r=0.96,EVLWIST vs.EVLWITD in 209 intensive care patients,减少血管外肺水:临床试验,Mitchell et al,Am Rev Resp Dis 145:990-998,1992,血管外肺水,血管外肺水(EVLW)通过经肺热稀释法得到,已被染料稀释法和重量法证实已证实血管外肺水(EVLW)与ARDS的严重程
43、度,病人机械通气的天数,住ICU的时间及死亡率明确相关,其评估肺水肿远远优于胸部X线肺血管通透性指数(PVPI)一定程度上反映了肺水肿形成的原因PVPI=EVLW/PBV,隐匿性肺水肿的检测,原发性与继发性ARDS/ALI的鉴别,患者人群(n=10)原发性ARDS/ALI(n=4):肺炎,误吸继发性ARDS/ALI(n=6):全身性感染评价指标ITBVIEVLWIPVPI(EVLW/ITBV),Morisawa K,Taira Y,Takahashi H,Matsui K,Ouchi M,Fujinawa N,Noda K.Do the data obtained by the PiCCO s
44、ystem enable one to differentiate between direct ALI/ARDS and indirect ALI/ARDS?Critical Care 2006,10(Suppl 1):P326(doi:10.1186/cc4673),原发性与继发性ARDS/ALI的鉴别,Morisawa K,Taira Y,Takahashi H,Matsui K,Ouchi M,Fujinawa N,Noda K.Do the data obtained by the PiCCO system enable one to differentiate between di
45、rect ALI/ARDS and indirect ALI/ARDS?Critical Care 2006,10(Suppl 1):P326(doi:10.1186/cc4673),SIRS及ARDS:肺血管通透性与肺水肿,Tagami T,Kushimoto S,Atsumi T,Matsuda K,Miyazaki Y,Oyama R,Koido Y,Kawai M,Yokota H,Yamamoto Y.Investigation of the pulmonary vascular permeability index and extravascular lung water in p
46、atients with SIRS and ARDS under the PiCCO system.Critical Care 2006;10(Suppl 1):P352(doi:10.1186/cc4699),血管外肺水的测定,胸片,氧合障碍及PAWP与EVLW之间的相关性很差床旁测定EVLW为危重病患者的诊断,随访及治疗评估提供了新的方法,PiCCO,技术问题,热稀释法测定心输出量,目的:确定热稀释法一次测定心输出量是否准确方法:回顾分析18名神经外科ICU患者共417次测定,1465次操作ANOVA分析,Wolf S,Plev D,Schrer L,Lumenta C.The repea
47、tability of transpulmonary thermodilution measurements.Critical Care 2004;8(Suppl 1):P57(DOI 10.1186/cc2524),热稀释法测定心输出量,Wolf S,Plev D,Schrer L,Lumenta C.The repeatability of transpulmonary thermodilution measurements.Critical Care 2004;8(Suppl 1):P57(DOI 10.1186/cc2524),热稀释法测定心输出量,目的:确定热稀释法测定心输出量时2次
48、测定与3次测定的准确性方法:回顾分析2年期间PiCCO监测的所有数据共25名感染性休克患者共249次心输出量测定比较前2次(M1)与3次测定心输出量(M2)的平均值,Alaya S,Abdellatif S,Nasri R,Ksouri H,Ben Lakhal S.PiCCO monitoring are two injections enough?Critical Care 2007;11(Suppl 2):P293,热稀释法测定心输出量,Alaya S,Abdellatif S,Nasri R,Ksouri H,Ben Lakhal S.PiCCO monitoring are two
49、injections enough?Critical Care 2007;11(Suppl 2):P293,43%,热稀释法测定心输出量,结论采用PiCCO进行监测时,2次热稀释法显然不足以可靠地测定心输出量,Alaya S,Abdellatif S,Nasri R,Ksouri H,Ben Lakhal S.PiCCO monitoring are two injections enough?Critical Care 2007;11(Suppl 2):P293,中心静脉插管部位的影响,Schmidt S,Westhoff TH,Hofmann C,Schaefer J-H,Zidek W,
50、Compton F,van der Giet M.Effect of the venous catheter site on transpulmonary thermodilution measurement variables.Crit Care Med 2007;35:783-786,颈内静脉vs.股静脉,中心静脉插管部位的影响,Schmidt S,Westhoff TH,Hofmann C,Schaefer J-H,Zidek W,Compton F,van der Giet M.Effect of the venous catheter site on transpulmonary t
